Provider Demographics
NPI:1205597481
Name:KEIM, JENNIFER EMMA
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:EMMA
Last Name:KEIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:522 SHORE RD APT 3K
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11561-4554
Mailing Address - Country:US
Mailing Address - Phone:347-272-9755
Mailing Address - Fax:
Practice Address - Street 1:259 1ST ST
Practice Address - Street 2:
Practice Address - City:MINEOLA
Practice Address - State:NY
Practice Address - Zip Code:11501-3957
Practice Address - Country:US
Practice Address - Phone:347-272-9755
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-10
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY432169363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care